Adrian MacKenzie

The Epidemiology of Inflammatory Bowel Disease in Canada: A Population-Based Study

BACKGROUND:Previously, we have demonstrated a high incidence and prevalence of Crohns disease (CD) and ulcerative colitis (UC) in the Canadian province of Manitoba. However, the epidemiology of inflammatory bowel disease (IBD) in other regions of Canada has not been defined. The aim of this study was to estimate the incidence and prevalence of CD and UC in diverse regions of Canada and the overall burden of IBD in Canada.METHODS:We applied a common case identification algorithm, previously validated in Manitoba to the provincial health databases in British Columbia (BC), Alberta (AB), Saskatchewan (SK), Manitoba (MB), and Nova Scotia (NS) to determine the age-adjusted incidence rates per 100,000 person-years for 1998–2000 and prevalence per 100,000 for mid 2000 and to estimate the IBD burden in Canada. Poisson regression was used to assess differences in incidence rates and prevalence by gender, age, and province.RESULTS:The incidence rate for CD ranged from 8.8 (BC) to 20.2 (NS), and for UC ranged from 9.9 (BC) to 19.5 (NS). The prevalence of CD was approximately 15- to 20-fold higher than the incidence rate, ranging from 161 (BC) to 319 (NS). This was similar for the prevalence of UC, which ranged from 162 (BC) to 249 (MB). Adjusting for age and province, the female:male ratio for incidence ratio was 1.31 (p < 0.0001) for CD and 1.02 (n.s.) for UC and was mostly stable across the five provinces.CONCLUSIONS:Approximately 0.5% of the Canadian population has IBD. Canada has the highest incidence and prevalence of CD yet reported.

Human Resources Planning and the Production of Health: A Needs-Based Analytical Framework

Traditional approaches to health human resources planning emphasize the effects of demographic change on the needs for health human resources. Planning requirements are largely based on the size and demographic mix of the population applied to simple population-provider or population-utilization ratios. We develop an extended analytical framework based on the production of health-care services and the multiple determinants of health human resource requirements. The requirements for human resources are shown to depend on four separate elements: demography, epidemiology, standards of care, and provider productivity. The application of the framework is illustrated using hypothetical scenarios for the population of the combined provinces of Atlantic Canada.

Excess Cancer Mortality in Psychiatric Patients

Objectives: There are conflicting data on cancer incidence and mortality in psychiatric patients, although most studies suggest that while cancer mortality is higher, incidence is no different from that in the general population. Different methodologies and outcomes may account for some of the conflicting results. We investigated the association between mental illness and cancer incidence, first admission rates, and mortality in Nova Scotia using a standard methodology. Method: A population-based record-linkage study of 247 344 patients in contact with primary care or specialist mental health services during 1995 to 2001 was used. Records were linked with cancer registrations and death records. Results: Cancer mortality was 72% higher in males (95%CI, 63% to 82%) and 59% higher in females (95%CI, 49% to 69%) among patients in contact with mental health services. This was reflected in similarly elevated first admission rates. However, there was weaker and less consistent evidence for increased incidence. For several cancer sites, incidence rate ratios were lower than might be expected given the mortality and first admission rate ratios, and no higher than that of the general population. These were melanoma, prostate, bladder, and colorectal cancers in males. Conclusion: People with mental illness in Nova Scotia have increased mortality from cancer, which cannot always be explained by increased incidence. Possible explanations for further study include delays in detection or initial presentation leading to more advanced staging at diagnosis, and difficulties in communication or access to health care.

Pilot-testing service-based planning for health care in rural Zambia

BackgroundHuman resources for health (HRH) planning in Zambia, as in other countries, is often done by comparing current HRH numbers with established posts, without considering whether population health needs are being met. Service-based HRH planning compares the number and type of services required by populations, given their needs, with the capacity of existing HRH to perform those services. The objective of the study was to demonstrate the effectiveness of service-based HRH planning through its adaptation in two rural Zambian districts, Gwembe and Chibombo.MethodsThe health conditions causing the greatest mortality and morbidity in each district were identified using administrative data and consultations with community health committees and health workers. The number and type of health care services required to address these conditions were estimated based on their population sizes, incidence and prevalence of each condition, and desired levels of service. The capacity of each district’s health workers to provide these services was estimated using a survey of health workers (n=44) that assessed the availability of their specific competencies.ResultsThe primary health conditions identified in the two districts were HIV/AIDS in Gwembe and malaria in Chibombo. Although the competencies of the existing health workforces in these two mostly aligned with these conditions, some substantial gaps were found between the services the workforce can provide and the services their populations need. The largest gaps identified in both districts were: performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a patient’s medical history, performing a physical examination, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment.ConclusionsAlthough active, productive, and competent, health workers in these districts are too few to meet the leading health care needs of their populations. Given the specific competencies most lacking, on-site training of existing health workers to develop these competencies may be the best approach to addressing the identified gaps. Continued use of the service-based approach in Zambia will enhance the country’s ability to align the training, management, and deployment of its health workforce to meet the needs of its people.RésuméContexteEn Zambie, comme dans d’autres pays, la planification des ressources humaines en santé consiste souvent à comparer les données sur les ressources et le nombre de postes établis, sans égard aux besoins de la population en matière de santé. La planification fondée sur les services consiste à comparer le nombre et le type de services requis par les populations, en fonction de leurs besoins, et la capacité des ressources existantes à fournir ces services. L’étude avait pour but de mettre en oeuvre la planification des ressources humaines en santé fondée sur les services dans deux districts ruraux de la Zambie – Gwembe et Chibombo – afin d’en démontrer l’efficacité.MéthodesAu moyen des données administratives et de la consultation des comités de santé communautaire et des travailleurs de la santé, on a cerné les problèmes de santé qui causent le plus de mortalité et de morbidité dans chaque district. Le nombre et le type de services de santé requis pour traiter ces problèmes ont été estimés en fonction de la taille de la population, de l’incidence et de la prévalence de chaque problème et des niveaux de service souhaités. La capacité des travailleurs de la santé de chaque district à fournir ces services a été estimée grâce à une enquête menée auprès de ces travailleurs (n = 44), qui a évalué leurs compétences particulières.RésultatsLes principaux problèmes de santé relevés étaient le VIH/sida dans le district de Gwembe et le paludisme dans le district de Chibombo. Si les compétences des travailleurs de la santé de ces deux districts cadraient en grande partie avec ces problèmes, d’importants écarts ont été décelés entre les services fournis par ces travailleurs et les services dont ont besoin les populations qu’ils servent. Les écarts les plus importants qui ont été relevés dans les deux districts avaient trait aux éléments suivants : les tests en laboratoire et l’interprétation des résultats, l’imagerie diagnostique et l’interprétation des résultats, la vérification et l’interprétation des antécédents médicaux des patients, l’examen physique, le dépistage et le diagnostic de la maladie et l’évaluation de l’admissibilité au traitement antirétroviral.ConclusionsBien qu’ils soient actifs, productifs et compétents, les travailleurs de la santé de ces districts sont trop peu nombreux pour répondre aux principaux besoins de la population en matière de santé. Compte tenu des compétences particulières où les lacunes sont les plus grandes, offrir une formation en milieu de travail aux travailleurs de la santé actuels afin qu’ils acquièrent ces compétences pourrait être la meilleure approche pour réduire les écarts qui ont été relevés. L’utilisation continue de cette approche fondée sur les services en Zambie améliorera la capacité du pays à penser la formation, la gestion et le déploiement de ses travailleurs en santé en fonction des besoins de sa population.

An Applied Simulation Model for Estimating the Supply of and Requirements for Registered Nurses Based on Population Health Needs

Aging populations, limited budgets, changing public expectations, new technologies, and the emergence of new diseases create challenges for health care systems as ways to meet needs and protect, promote, and restore health are considered. Traditional planning methods for the professionals required to provide these services have given little consideration to changes in the needs of the populations they serve or to changes in the amount/types of services offered and the way they are delivered. In the absence of dynamic planning models that simulate alternative policies and test policy mixes for their relative effectiveness, planners have tended to rely on projecting prevailing or arbitrarily determined target provider—population ratios. A simulation model has been developed that addresses each of these shortcomings by simultaneously estimating the supply of and requirements for registered nurses based on the identification and interaction of the determinants. The model’s use is illustrated using data for Nova Scotia, Canada.

In place of fear: aligning health care planning with system objectives to achieve financial sustainability

The financial sustainability of publicly funded health care systems is a challenge to policymakers in many countries as health care absorbs an ever increasing share of both national wealth and government spending. New technology, aging populations and increasing public expectations of the health care system are often cited as reasons why health care systems need ever increasing funding as well as reasons why universal and comprehensive public systems are unsustainable. However, increases in health care spending are not usually linked to corresponding increases in need for care within populations. Attempts to promote financial sustainability of systems such as limiting the range of services is covered or the groups of population covered may compromise their political sustainability as some groups are left to seek private cover for some or all services. In this paper, an alternative view of financial sustainability is presented which identifies the failure of planning and management of health care to reflect needs for care in populations and to integrate planning and management functions for health care expenditure, health care services and the health care workforce. We present a Health Care Sustainability Framework based on disaggregating the health care expenditure into separate planning components. Unlike other approaches to planning health care expenditure, this framework explicitly incorporates population health needs as a determinant of health care requirements, and provides a diagnostic tool for understanding the sources of expenditure increase.

Health worker migration from South Africa: causes, consequences and policy responses

BackgroundThis paper arises from a four-country study that sought to better understand the drivers of skilled health worker migration, its consequences, and the strategies countries have employed to mitigate negative impacts. The four countries—Jamaica, India, the Philippines, and South Africa—have historically been “sources” of skilled health workers (SHWs) migrating to other countries. This paper presents the findings from South Africa.MethodsThe study began with a scoping review of the literature on health worker migration from South Africa, followed by empirical data collected from skilled health workers and stakeholders. Surveys were conducted with physicians, nurses, pharmacists, and dentists. Interviews were conducted with key informants representing educators, regulators, national and local governments, private and public sector health facilities, recruitment agencies, and professional associations and councils. Survey data were analyzed using descriptive statistics and regression models. Interview data were analyzed thematically.ResultsThere has been an overall decrease in out-migration of skilled health workers from South Africa since the early 2000s largely attributed to a reduced need for foreign-trained skilled health workers in destination countries, limitations on recruitment, and tighter migration rules. Low levels of worker satisfaction persist, although the Occupation Specific Dispensation (OSD) policy (2007), which increased wages for health workers, has been described as critical in retaining South African nurses. Return migration was reportedly a common occurrence. The consequences attributed to SHW migration are mixed, but shortages appear to have declined. Most promising initiatives are those designed to reinforce the South African health system and undertaken within South Africa itself.ConclusionsIn the near past, South Africa’s health worker shortages as a result of emigration were viewed as significant and harmful. Currently, domestic policies to improve health care and the health workforce including innovations such as new skilled health worker cadres and OSD policies appear to have served to decrease SHW shortages to some extent. Decreased global demand for health workers and indications that South African SHWs primarily use migratory routes for professional development suggest that health worker shortages as a result of permanent migration no longer pertains to South Africa.

A synthesis of recent analyses of human resources for health requirements and labour market dynamics in high-income OECD countries.

BackgroundRecognition of the importance of effective human resources for health (HRH) planning is evident in efforts by the World Health Organization (WHO) and the Global Health Workforce Alliance (GHWA) to facilitate, with partner organizations, the development of a global HRH strategy for the period 2016–2030. As part of efforts to inform the development of this strategy, the aims of this study, the first of a pair, were (a) to conduct a rapid review of recent analyses of HRH requirements and labour market dynamics in high-income countries who are members of the Organisation for Economic Co-operation and Development (OECD) and (b) to identify a methodology to determine future HRH requirements for these countries.MethodsA systematic search of peer-reviewed literature, targeted website searches, and multi-stage reference mining were conducted. To supplement these efforts, an international Advisory Group provided additional potentially relevant documents. All documents were assessed against predefined inclusion criteria and reviewed using a standardized data extraction tool.ResultsIn total, 224 documents were included in the review. The HRH supply in the included countries is generally expected to grow, but it is not clear whether that growth will be adequate to meet health care system objectives in the future. Several recurring themes regarding factors of importance in HRH planning were evident across the documents reviewed, such as aging populations and health workforces as well as changes in disease patterns, models of care delivery, scopes of practice, and technologies in health care. However, the most common HRH planning approaches found through the review do not account for most of these factors.ConclusionsThe current evidence base on HRH labour markets in high-income OECD countries, although large and growing, does not provide a clear picture of the expected future HRH situation in these countries. Rather than HRH planning methods and analyses being guided by explicit HRH policy questions, most of the reviewed studies appeared to derive HRH policy questions based on predetermined planning methods. Informed by the findings of this review, a methodology to estimate future HRH requirements for these countries is described.

Needs-based human resources for health planning in Jamaica: using simulation modelling to inform policy options for pharmacists in the public sector

BackgroundPlanning for human resources for health (HRH) is central to health systems strengthening around the world, including in the Caribbean and Jamaica. In an effort to align Jamaica’s health workforce with the changing health needs of its people, a partnership was established between Jamaican and Canadian partners. The purpose of the work described in this paper is to describe the development and application of a needs-based HRH simulation model for pharmacists in Jamaica’s largest health region.MethodsGuided by a Steering Committee of Jamaican stakeholders, a simulation modelling approach originally developed in Canada was adapted for the Jamaican context. The purpose of this approach is to promote understanding of how various factors affect the supply of and/or requirements for HRH in different scenarios, and to identify policy levers for influencing each of these under different future scenarios. This is done by integrating knowledge of different components of the health care system into a single tool that shows how changes to different parameters affect HRH supply or requirements. Data to populate the model were obtained from multiple administrative databases and key informants. Findings were validated with the Steering Committee.ResultsThe model estimated an initial shortage of 110 full-time equivalent (FTE) pharmacists in the South East Region that, without intervention, would increase to a shortage of about 150 FTEs over a 15-year period. In contrast to the relatively small impact of a large enrolment increase in Jamaica’s pharmacy training programme, interventions to increase recruitment of pharmacists to the public sector, or improve productivity - through, for example, the use of support staff and/or new technologies - may have much greater impact on reducing this shortage.ConclusionsThe model represents an improvement on the HRH planning tools previously used in Jamaica in that it supports the estimation of HRH requirements based directly on measures of population health need. Both the profession (pharmacists) and country (Jamaica) considered here are under-studied. Further investments by Jamaica’s MoH in continuing to build capacity to use such models, in combination with their efforts to enhance health information systems, will support better informed HRH planning in Jamaica.

Evaluation of recruitment and retention strategies for health workers in rural Zambia

BackgroundIn response to Zambia’s critical human resources for health challenges, a number of strategies have been implemented to recruit and retain health workers in rural and remote areas. Prior to this study, the effectiveness of these strategies had not been investigated. The purpose of this study was to determine the impacts of the various health worker retention strategies on health workers in two rural districts of Zambia.MethodsUsing a modified outcome mapping approach, cross-sectional qualitative and quantitative data were collected from health workers and other stakeholders through focus group discussions and individual interview questionnaires and were supplemented by administrative data. Key themes emerging from qualitative data were identified from transcripts using thematic analysis. Quantitative data were analyzed descriptively as well as by regression modelling. In the latter, the degree to which variation in health workers’ self-reported job satisfaction, likelihood of leaving, and frequency of considering leaving, were modelled as functions of participation in each of several retention strategies while controlling for age, gender, profession, and district.ResultsNineteen health worker recruitment and retention strategies were identified and 45 health care workers interviewed in the two districts; participation in each strategy varied from 0% to 80% of study participants. Although a salary top-up for health workers in rural areas was identified as the most effective incentive, almost none of the recruitment and retention strategies were significant predictors of health workers’ job satisfaction, likelihood of leaving, or frequency of considering leaving, which were in large part explained by individual characteristics such as age, gender, and profession. These quantitative findings were consistent with the qualitative data, which indicated that existing strategies fail to address major problems identified by health workers in these districts, such as poor living and working conditions.ConclusionsAlthough somewhat limited by a small sample size and the cross-sectional nature of the primary data available, the results nonetheless show that the many health worker recruitment and retention strategies implemented in rural Zambia appear to have little or no impact on keeping health workers in rural areas, and highlight key issues for future recruitment and retention efforts.RésuméContexteEn réponse aux problèmes de pénuries des ressources humaines dans le domaine de la santé en Zambie, un certain nombre de stratégies ont été mises en oeuvre pour recruter et maintenir en poste les travailleurs de la santé dans les régions rurales et éloignées. Avant cette étude, l’efficacité de ces stratégies n’avait pas été étudiée. L’objectif de cette étude était donc de déterminer l’incidence de différentes stratégies de maintien en poste de différents corps de métiers de la santé dans deux districts ruraux de la Zambie.MéthodesAu moyen d’une cartographie des incidences modifiée, des données transversales qualitatives et quantitatives ont été recueillies auprès des travailleurs de la santé et d’autres intervenants grâce à des groupes de discussion et des questionnaires individuels auxquels ont été intégrés des données administratives. Les principaux thèmes ont été dégagés des données qualitatives grâce à la transcription des discussions au moyen de l’analyse thématique. Les données quantitatives ont été analysées de façon descriptive ainsi qu’à l’aide d’un modèle de régression. Pour ce dernier, le degré de variation de la satisfaction par rapport à l’emploi, de la probabilité de quitter l’emploi et de la fréquence à laquelle les travailleurs pensaient à quitter leur emploi a été modelé en fonction de leur participation à chacune des différentes stratégies de maintien en poste, tout en considérant des données sur l’âge, le sexe, la profession et le district.RésultatsPas moins de 19 stratégies de recrutement et de maintien en poste ont été dénombrées auprès des 45 travailleurs de la santé interviewés dans les deux districts. La participation à chacune des stratégies variait de 0 à 80 % selon les participants à l’étude. Bien que les suppléments de rémunération pour les travailleurs de la santé dans les régions rurales constituent les mesures incitatives les plus efficaces, presque aucune stratégie de recrutement et de maintien en poste n’était un bon indicateur de la satisfaction face à l’emploi, de la probabilité de le quitter et de la fréquence à laquelle les travailleurs pensaient à quitter leur emploi. Ces facteurs étaient, dans une large part, expliqués par les caractéristiques des travailleurs comme l’âge, le sexe et la profession. Ces résultats quantitatifs étaient conformes aux données qualitatives, qui indiquaient que les stratégies de recrutement et de maintien en poste ne permettaient pas de régler les principaux problèmes déterminés par les travailleurs de la santé de ces districts, notamment des conditions de vie et de travail difficiles.ConclusionsMalgré la taille de l’échantillon limitée et la nature transversale des données primaires disponibles, les résultats montrent néanmoins que les nombreuses stratégies de recrutement et de maintien en poste mises en oeuvre en Zambie rurale n’ont que peu ou pas du tout d’incidence sur le maintien en poste des travailleurs de la santé dans les régions rurales et mettent en lumière des problèmes de recrutement et de maintien en poste clés.